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CENTER NAME:FISCAL YEAR:2025PART 1 Participant InformationFirst and Last Name(s) of Adult Participant(s) Date of Birthmark 2 BENEFITS FROM MEDICAID, SUPPLEMENTAL SECURITY INCOME (SSI), and/or SNAP
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Who needs utilizing form spend down?

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Individuals who are required to spend down their assets in order to qualify for certain benefits or assistance programs.
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Utilizing form spend down is a form used to report the spend down of allocated funds.
Any organization or individual who has received allocated funds and needs to report on how those funds were spent is required to file utilizing form spend down.
Utilizing form spend down can be filled out by providing detailed information on how the allocated funds were spent, including expenses and proof of payments.
The purpose of utilizing form spend down is to track and report on the usage of allocated funds in order to ensure transparency and accountability.
Information such as total allocated funds, detailed breakdown of expenses, proof of payments, and any remaining balance must be reported on utilizing form spend down.
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